OptumRx® Provider Manual Updates May Shift Audits – Especially LTC
OptumRx® updates their Provider Manual several times throughout the year and publishes the full version on its publicly available webpage. Since a PBM’s Provider Manual is an extension of their contract, the terms and conditions within the Provider Manual are expected to be followed and non-adherence can cause problems for pharmacies. Such problems may consist of audit chargebacks, fraud, waste and abuse investigations, and even contract termination.
The latest OptumRx® Provider Manual publication is the 2024 Fourth Edition Version 4.1. PAAS National® analysts want you to be aware of the following changes and potential implications it will have on the documents you maintain and provide for an audit as well as changes you may see in your audit results report.
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- Long-Term Care (LTC) Pharmacy –
- The following language was removed from the OptumRx® Provider Manual, “Documentation of a valid prescription order shall be comprised of a signed Prescriber’s order and a medication administration record (MAR) for a time period that supports the audited dates of service. All signed Prescriber’s orders must be supplemented by a MAR to help ensure Members are receiving the appropriate therapy and not therapy that has been discontinued or changed since the last Prescriber’s order.“
- What remains is the following, “Network Pharmacy Providers are expected to adhere to these requirements for what constitutes a valid prescription order unless otherwise specified in applicable state laws and regulations. Record retention is important, and timely retrieval of these documents shall be in compliance with audit requirements.”
- The potential implication of this change is that it may be more difficult to determine the exact requirements for a “valid prescription order” since many states do not specifically delineate LTC order requirements from retail prescription requirements. Previously, the pharmacy could submit the MAR or other facility documents to help validate the prescription order, but those records may no longer carry the same weight as they once did. Many discrepancy codes related to LTC documentation have also been removed from OptumRx’s discrepancy code list since they will no longer be applicable.
- Discrepancy Code Changes –
| Modified Codes | ||||
| Code | Old Definition | New Definition | Implication | |
| 1K Incorrect use of Dispense as Written Code | “Partial Recoupment: reverse and rebill claim with manual cost override at the generic cost (for the brand NDC)” | “Recoupment dependent on billing” | It remains to be seen if this will be a positive, neutral, or negative change. PAAS analysts have seen recoupment on multi-source brand claims billed with DAW 9 (substitution allowed by prescriber but plan prefers brand) because the plan claimed DAW 0 was appropriate, and the DAW 9 was unsubstantiated. In this scenario, there was no concrete evidence from the PBM to indicate the brand was preferred, therefore the PBM stated the multi-source brand should have been billed with a DAW 0. | |
| 1N Days’ Supply on Claim is Incorrect | “Educational” | “Recoupment dependent on billing” | PAAS analyst have already seen the implementation of this change in audit results, and it definitely has a negative impact on pharmacies. Previously, a claim flagged only with an invalid days’ supply discrepancy would have $0 chargeback. Now, analyst have seen chargebacks, usually in an amount which corresponds to the difference in the patient’s copay once the days’ supply is corrected. | |
| Codes Removed | ||||
| Code | Code Description | Definition | ||
| 1T | Used smaller size product for larger stock size billed | Educational | ||
| 2F | Billed Appropriate No discrepancy adjustment | Educational | ||
| 3P | Invalid Rx | Missing LTC MAR | ||
| 3R | Invalid Rx | Missing LTC refill request form | ||
| 3S | Invalid Rx | Missing patient attestation letter indicating the patient received and consumed the medication | ||
| 3T | Invalid Rx | Missing LTC facility attestation letter indicating the facility requested/ordered/received the medication | ||
| 3U | Invalid Rx | Missing LTC nurse as prescriber agent contract | ||
The ever-changing OptumRx® Provider Manual is just another whirlwind which pharmacies are caught in and must learn to navigate. Remember, PAAS is here to help, and our dedicated team is just a phone call, email, or web inquiry away!
PAAS Tips:
- Ensure all prescriptions are valid and complete per federal and state law, including LTC orders
- Follow Humana’s long-term care pharmacy documentation guidelines as they the most detailed for LTC
- For more information on DAW code documentation, check out the following resources:
- February 2024 Newsline article, Best Practices for DAW Billing in Pharmacies
- PAAS Tool: DAW Codes Explained
- Familiarize yourself with additional invalid days’ supply concerns by reading this month’s Newsline, Avoid OptumRx® Double Chargeback Pitfalls – Review Your Days’ Supply
Analyst at PAAS National®
After graduating from UW-Madison's School of Pharmacy with my PharmD, I spent my first eight years at an independent pharmacy dividing my time between both retail and long-term care. I fell in love with the independent pharmacy world and joined the PAAS team to help independents not only survive, but thrive.
I enjoy assisting pharmacy staff both pre- and post-audit and enjoy providing them with knowledge and tools to decrease audit risk going forward. I write articles for Third-Party Newsline each month and answer member questions daily. I look forward to building professional relationships with each of our members and assisting you with your next audit.
I enjoy assisting pharmacy staff both pre- and post-audit and enjoy providing them with knowledge and tools to decrease audit risk going forward. I write articles for Third-Party Newsline each month and answer member questions daily. I look forward to building professional relationships with each of our members and assisting you with your next audit.
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